=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942862719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY QUEST WOODBINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2019
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1449 DEHIRSCH AVE APT 1
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08270-2454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-861-3044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6814 TILTON RD
-----------------------------------------------------
City | EGG HARBOR TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08234-4490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-646-0388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KERRIE JEAN KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-646-0388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------